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Mainstream Application for Section 8 Housing Choice Voucher Waiting List

Mainstream Application for Section 8 Housing Choice Voucher Waiting List

Mainstream Application For Section 8 Housing Choice Voucher Waiting List

Please use attached instructions to complete and submit this application. Application must be submitted with a completed and signed Mainstream Preference Packet. Applications will not be accepted without a Mainstream Preference Packet.

Return completed applications and Mainstream Preference Packets in one of the following ways: . By Mail or In Person: Home Forward – Rent Assistance, 135 SW Ash Street, Portland OR 97204 . Fax: (503) 802-8330 Attention: HCV Waitlist . Email: [email protected]

Applications will only be accepted 3/18/2019 – 3/22/2019. Applications will not be accepted before 3/18/2019 or after 3/22/2019.

If you or anyone in your family is a person with disabilities, and you require a specific accommodation in order to fully utilize our programs and services, please contact Home Forward at 503-415-8040.

INFORMATION ABOUT HEAD OF HOUSEHOLD

Social Security Number: ______--______--______Date of Birth:______/______/______Gender: □ F □ M □ X

Last Name:______First Name:______Middle Initial:_____

Telephone Number:______E-mail Address:______

Ethnicity (check one box) Race (check all that apply): □ Hispanic □ White □ Black / African American □ American Indian / Alaska Native □ Non-Hispanic □ Asian □ Native Hawaiian / Other Pacific Islander Racial and ethnic data for statistical purposes only What is the primary language spoken in your home? (for information only, to better serve you) ______Do you need an interpreter? (for information only, to better serve you) □ Yes □ No

Mailing Address, if different from Legal Legal Address (where you currently live) (where you currently receive mail) Address Address

City City

State State

Zip Code Zip Code

Note: The address you supply on this application will be applied to any current application you have for any Home Forward housing program (if applicable). If your legal or mailing address changes, you must notify Home Forward in writing to maintain your waiting list status.

HOUSEHOLD MEMBERS List information for adults first, then children under age 18. Use “F”, “M” or “X” to indicate gender. If a household member qualifies for a reasonable accommodation due to a disability, indicate “Yes”; if not, indicate “No”. List relationship of each person to the Head of Household. If additional space is needed, use a separate sheet and attach it to this application. Social Security Disabled Relationship First Name Last Name Date of Birth Gender Number (Yes/No)

Head

Spouse / Co-head

□ Check this box if a separate sheet listing other household members is attached.

This form is available in English, Spanish, Russian, and Vietnamese Over HOUSEHOLD INCOME

What is the total gross monthly income (before taxes) for your household? $ ______Include all payments received by each family member age 18 or older, such as wages, military pay, pensions, social security, SSI, welfare, child support, , business, profession, or any other source.

ELIGIBILITY AND PREFERENCES

Your response to the following questions will help determine your eligibility for rental assistance and if you are entitled to a preference when placed on the program’s waiting list. Select the appropriate responses for each question below.

Will your household include a family member who is between the ages of 18 and 61 □ Yes □ No years, and is a person with a disability? Will this person (or has this person) be transitioning out of an institution or segregated □ Yes □ No setting within 90 days of this application?

OPTIONAL Home Forward Advocacy Form

You have the right to include as part of your application contact information for a person or organization that may be helping you complete your application or coordinate supportive services. If you would like Home Forward to speak with a case manager, advocate or family member not included in this application, please complete and return the attached Home Forward Advocacy Form. You are not required to provide this contact information, □ Check this box if you choose not to provide the contact information.

U.S. CITIZENSHIP NOTIFICATION AND CERTIFICATION

PLEASE READ THIS AUTHORIZATION CAREFULLY AND SIGN BELOW: By submitting this application for Section 8 voucher assistance, I authorize Home Forward to verify all information I supplied within the application. I also authorize Home Forward to determine the eligibility of my household for housing assistance by examining criminal background records and citizenship status. I understand that providing false information is grounds for denial of housing assistance. By submitting this form, I certify that the information on this form is true and complete to the best of my knowledge and belief. I understand that I can be fined up to $10,000 or imprisoned up to five years if I furnish false or incomplete information.

______Signature of Head of Household Date

______Signature of Spouse / Co-head Date

______Signature of Other Adult Date

______Signature of Other Adult Date

______Signature of Other Adult Date

______Signature of Other Adult Date

Please mail this completed application and Mainstream Preference Packet to Home Forward as requested, using instructions attached to this form. Applications will not be accepted before 3/18/2019 or after 3/22/2019. If your legal or mailing address changes, you must notify Home Forward in writing to maintain your waiting list status. If Home Forward does not have your current mailing address, your application will be removed from the waiting list.

Rent Assistance Department 135 SW Ash Street Portland, OR 97204-3541 TEL: 503.802.8333 FX: 503.802.8330 TTY: 503.802.8554

Statement of Eligibility for Mainstream Voucher Preference Instructions: . Please complete and sign this form below if you believe your household is eligible for the Mainstream Voucher Preference . If you or anyone in your family is a person with disabilities and you require a specific accommodation to fully utilize our programs and services, please contact 503 415-8050.

Program Information: . To be eligible for this preference, your household must include a family member who: ☐ Has a disability, and ☐ Is between the ages of 18 and 61 years, and ☐ Is transitioning out of an institutional or other segregated setting. . Eligible household can be a single person if person meets preference criteria listed above.

Household Information Head of Household Name: Last four numbers of SSN: Name of Eligible Family Member:

Date of Birth of Eligible Family Member:

☐Attach Proof of Age such as a copy of Photo ID

Verification of Disability

Please attach the requested verification.

☐ Benefit Letter from Social Security Administration dated within past 60 days, or

☐ Verification of Disability Form completed by a qualified professional, such as a doctor, other medical professional, or licensed clinical social worker.

Verification of Transition from Institutional or Other Segregated Setting Institutional and other segregated settings include, but are not limited to: . Congregate settings populated exclusively or primarily with individuals with disabilities; or

. Congregate settings characterized by regimentation in daily activities, lack of or autonomy, policies limiting visitors, or limits on individuals’ ability to engage freely in community activities and to manage their own activities of daily living; or

. Settings that provide daytime activities primarily with other individuals with disabilities.

Transitioning is defined as having a plan for exiting an institutional or other segregated settings within three months.

☐ Attach Written Verification of Transition Plan such as a letter from staff at the facility or from another service provider describing the setting and confirming that the eligible family member has a plan to exit within three months.

Name of Institution/Segregated setting: Phone:

Name of someone who can verify transition plan: Title:

Certification Warning: Section 1001 of Title 18 of the US Code makes it a criminal offense to make any willful false statements or misrepresentations to any Department or Agency of the as to any matter within its jurisdiction, punishable by fine not to exceed $10,000 and/or imprisonment of not more than 5 years. I certify the information in this Statement of Eligibility is true and accurate.

Head of Household Signature: Date:

MSV Statement of Eligibility - 10/2018

Mainstream Voucher & Coordinated Access for Adults and Families: Authorization for Disclosure of Confidential Information

The Mainstream Voucher Program provides rental assistance to non-elderly adults with disabilities so they can live in the community, not in institutions. Home Forward was recently awarded 99 of these vouchers.

Coordinated Access for Adults and Families is a network of non- organizations and agencies in Multnomah County that coordinates the delivery of rental assistance and supportive services to individuals and families. This network is partnering with Home Forward to help Mainstream Voucher recipients be successful. A full list of partner organizations can be found on the back of this form and online at www.ahomeforeveryone.net/coordinatedaccess.

Mainstream Voucher & Coordinated Access for Adults and Families: Authorization for Disclosure of Confidential Information Form allows communication between Home Forward and these partners. It is intended to reduce barriers and allow coordination of services within the network. Any information shared among these partners will not be released to other parties without additional written authorization from you.

The form is optional. Refusing to sign the form will not affect your eligibility or participation in the Mainstream Voucher Program. If you choose to sign the Mainstream Voucher & Coordinated Access for Adults and Families: Authorization for Disclosure of Confidential Information Form, please list the names and dates of birth for all household members.

Mainstream Voucher & Coordinated Access for Adults and Families : Authorization for Disclosure of Confidential Information

The Mainstream Voucher Program provides rental assistance to assist households which include non-elderly persons (age 18 to 61) with disabilities who are transitioning out of institutional or other segregated settings, at risk of institutionalization, homeless, or at risk of becoming homeless. Coordinated Access for Adults and Families is a network of separate agencies that coordinate the delivery of rental assistance and supportive services to individuals and families, primarily who are homeless, with priority for those with the longest history of homelessness and most service needs. This network partners with Home Forward to coordinate services for Mainstream Voucher recipients. A full list of Coordinated Access for Adults and Families partner agencies is available upon request and published online at ahomeforeveryone.net/coordinatedaccess.

Coordinated Access for Adults and Families agencies will enter the information you provide into a vendor-hosted Homeless Management Information System (HMIS), a computerized and secured record-keeping system known as ServicePoint. These agencies are required by law to maintain the privacy of your personal information. Your information will not be disclosed to other agencies without your authorization except as required or permitted by law.

By signing this form, I authorize the disclosure of my Client Record [Name, Social Security Number, and Veteran Status], Demographics [Date of Birth, Gender, Race, and Ethnicity], Mainstream Voucher and Coordinated Access related Program Enrollment and Exit Information, information about the nature of my situation, and Services and Referrals I receive, to Coordinated Access for Adults and Families partner agencies for the purpose of payment, health care operations activities and coordination of housing and related services.

I authorize the disclosure of the following categories of personal information (all adult household members participating in services initial): A. Mental Health Initial/s: ______

B. Substance use disorder diagnosis, treatment, and treatment referral. I understand Initial/s: ______that records disclosed made may be bound by Part 2 of Title 42 of the Code of Federal (CFR) governing confidentiality of substance use disorder records. Recipients of these records may re-disclose the records only with my written consent or as permitted by 42 CFR Part 2. C. HIV/AIDS Initial/s: ______

I understand that this information may include information that would otherwise be protected by Oregon and federal law. All Coordinated Access for Adults and Families participating agencies acknowledge that any information disclosed among these agencies will not be re-disclosed to other parties without my further written authorization, unless otherwise required or permitted by law.

This authorization becomes effective on the date below and will expire 12 months from my last date of participation in The Mainstream Voucher Program and/or Coordinated Access for Adults and Families; a period reasonably needed to complete the disclosure of information for the purposes described and named in this authorization unless I indicate otherwise. Specific expiration date: ______.

I may revoke this authorization at any time except to the extent that action has already been taken in reliance on it. Revocation of this authorization is effective upon receipt by a Coordinated Access for Adults and Families agency.

This authorization is voluntary. I may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment, payment, enrollment or eligibility for benefits. Refusing to sign this authorization may affect my engagement with Coordinated Access for Adults and Families, shared prioritization lists, and access to partner agencies. I may inspect or copy any information used and/or disclosed under this authorization. My signature below indicates I approve of this authorization and understand its meaning.

Please list the names and dates of birth of all household members participating in services:

______

______

______Client or Legal Guardian Name (please print) Client or Legal Guardian Signature Date

______Additional Adult’s Name (please print) Additional Adult Signature Date

ONLY COMPLETE THIS SECTION TO REVOKE PREVIOUS AUTHORIZATION

I revoke this authorization. Signature: ______Date: ______

Signature: ______Date: ______